Pott’s TB Disease of the Spine
“How are you?”  Aj
“How are you?”  Ajak * smiled shyly, reaching to shake my hand. Ajak was seven years old and proud of his English.  
“I am fine,” I answered, as we entered the tent reserved for children with tuberculosis and malnutrition.  
Ajak had arrived a month ago, in pain, his spine deformed with healed wounds from previous abscesses. He could hardly walk but had done his best to stand tall when introduced.  His grandmother had brought him from a village about forty minutes away by local transport. 
Over the first month of intensive TB therapy, Ajak blossomed. With our excellent nutrition support based on Ready to Use Therapeutic Food (RUTF) called Plumpy Nut, he began to gain back the weight ravaged by the ancient illness called Consumption. While his spine will remain with a forward bend of the upper back, he is no longer in pain and he has managed to avoid the risk of paralysis.  
In 1779, Sir Percivall Pott published a monograph describing the association between curvature of the spine and a spastic or stiff paralysis of the legs. 
In 1948 in a lecture delivered to the Royal College of Surgeon’s of England, G.R. Girdlestone outlined the treatment options for Pott’s Paraplegia, or loss of function of the legs caused by an infected curvature of the spine. He advocated fresh outdoor air, nutritious food and spinal immobilization for prolonged periods of time for children. 
The first anti-tubercular medication, streptomycin, became available for clinical use in 1947, not only ushering in the modern era of TB treatment but it remains an important medication for use today. Further medications for TB treatment continued to be developed, and by 1965 our standard first-line treatment medications, isoniazid, rifampicin, ethambutol and pyrazinamide became available.   
While every medical student  in Western Countries learns about Pott’s Disease, it is taught mostly as a quaint and historical problem. The first time I saw Ajak, I recognized the unique kyphotic bend in the spine; the scars from previous draining abscesses, but still I wondered aloud “is this is actually Pott’s Disease?”  
We don’t have the benefit of X-ray, and we can only test lung TB with sputum stained and examined under a microscope, so all other forms of TB are diagnosed by taking a careful history, and examination. It seems crude compared to all of the diagnostic tests available in Canada, but it works. I have now seen many desperately thin children not responding to therapeutic feeding turn around under the benefit TB treatment. The kids begin to put on weight then they begin with tentative smiles as if learning for the first time. Next, energy for gentle play, songs and laughter and finally, running or crawling and mischief, benefiting from the same cures used three hundred years ago; fresh air and nutrition as well as life-saving medication.  
Ajak is one of many children in our TB program. He will soon return home with his grandmother but will continue to be seen as an outpatient until he completes a full year of treatment.  While he arrived too late to avoid the curvature of his spine he loves to play outside and he is actively learning to read and write in Dinka and English with the help of our Dinka translator, Gabriel.   
Pott’s Disease is not a disease of historical interest.  Tuberculosis of the spine, the lungs, the organs is alive and thriving wherever poverty, poor housing and poor nutrition create pockets of vulnerable populations.  World TB Day on March 24th 2015 isn’t a quaint event either.  Much work remains to be done to avoid drug resistance and to battle the twin infections of TB and HIV. In Yida we are opening up a new TB area, with more space between tents, an area sheltered by trees, an area with room for a garden and for the kids to play, something really to celebrate!  
 *not his real name